Jane Scullion BAHons RGN MSc

Respiratory Nurse Consultant at University Hospitals of Leicester NHS Trust; Honorary Senior Lecturer at De Montfort University; Clinical Research Fellow at Aberdeen University

Jane Scullion is a Respiratory Nurse Consultant working across the interface of primary and secondary care with patients with chronic respiratory diseases and developing respiratory services. She has published widely and presented both nationally and internationally.

Diane Todd BSc(Hons) DipHE RM RGN

Specialist Midwife - Diabetes at the University Hospitals of

Leicester NHS Trust

Diane trained as a staff nurse in 1984 and gained several years experience in surgical speciality and intensive care nursing, after which she chose a career in midwifery.

Qualifying in 1992 much of her practice has focused on high-risk pregnancies, in particular those women who have diabetes. As part of a multi-disciplinary team she has further developed the care and service offered to these women, winning a Trent Travel Award in 1995, for a Leicester team to visit Edinburgh Royal Infirmary to learn more about pre-conception clinics and actively participating in the recent CEMACH Diabetes in pregnancy study. She has also undertaken specific courses to enhance her knowledge and skills and has presented at national and international levels.

Despite the considerable advances in maternity care, and world-class maternity services provided by highly trained and motivated health care professionals, good maternal health is not a given or a universal right even in countries with high quality functioning maternity services with their attendant very low maternal mortality and morbidity rates. And whilst we would all hope that pregnancy, birth and the early weeks of parenthood would be enjoyable and relatively comfortable experiences for new mothers, babies and families we know, sadly, that this is not always the case.

Not all mothers start pregnancy in the best of health, and others develop problems as they go along. The latest Confidential Enquiry into Maternal Deaths Report for 2003-2005, Saving Mothers' Lives, shows that more of our mothers died from pre-existing, or new, medical conditions aggravated by pregnancy than from the big obstetric killers of the past such as haemorrhage, sepsis and pre-eclampsia. These so-called 'indirect' maternal deaths have outnumbered those from causes directly related to pregnancy for more than 10 years. And each death is just the tip of the iceberg of severe morbidity and complications. In the last Saving Mothers' Lives report more women died from cardiac disease than from any other cause, including the leading 'directly' associated cause thrombo-embolism, and deaths from acquired heart disease brought on by unhealthy lifestyles and obesity are increasing at an alarming rate. These findings show that whilst the lessons for the management of common obstetric conditions have clearly had an impact in the past, maternity professionals need to be more aware of the impact of, and identification and management of medical conditions affecting pregnancy before conception and during and after pregnancy. This is what this book aims to achieve.

A number of factors have led to the increase in the proportion of pregnant women or new mothers who have more medically complex pregnancies. They include rising numbers of older or obese mothers, women whose lifestyles put them at risk of poorer health and a growing proportion of women with serious underlying medical conditions who would not have chosen, or have been able to become pregnant in the past. The rising numbers of births to women born outside the UK also affects the underlying general level of maternal health as these mothers often have more complicated pregnancies, more serious underlying medical conditions or may be in poorer general health.

This publication is therefore extremely timely. Its authors are to be congratulated for developing a highly readable, informative and practical book each chapter of which, in the best traditions of maternity care, has been written jointly by a midwife and obstetrician. Such partnership working is emphasised throughout the book, with a clear focus on each other's respective roles and responsibilities within the clinical team. The need for pre-pregnancy counselling and preparation for women living with conditions that are adversely affected by pregnancy, or which ideally require a change in treatment or medication prior to conception is also rightly highlighted as an important, but often overlooked aspect of obstetric medicine. Midwives, obstetricians and all other maternity team members together with those with a general interest in pregnancy and birth should find this book informative and easy to read. Acting on the important messages continued within each chapter should help lead to wider improvements in the understanding and management of mothers who need extra care to ensure they have as healthy and happy pregnancies, birth and babies as possible.

Gwyneth Lewis MBBS, MSc, MRCGP, FFPHM, FRCOG National Director for Maternal Health, England Director of the United Kingdom Confidential Enquiries into Maternal Deaths

Midwives are practising in a rapidly changing world with advances in technology, increasing expectations of mothers and pressure to provide a cost-effective service in state-funded health sectors. A modern maternity service that is flexible and adaptable with midwives open to both learning and change is advocated1. Innovative schemes of care have been developed, such as case-holding midwifery, concentrating on normal childbearing that foster autonomy in the midwife's practice.

The nature of the child-bearing woman is also changing, with women delaying pregnancy until their thirties and forties and sometimes beyond2. Whilst fertility and obstetrical aspects of such a delay are well documented, the association with medical disorders warrants attention. Advancing maternal age increases risk of chronic medical conditions3. A medical disorder can subsequently complicate pregnancy, or it can present for the first time in pregnancy4.

Knowledge of medical conditions is therefore necessary, first to avoid mothers being booked inappropriately for low-risk midwifery care schemes, and second for midwives to recognise the signs of deterioration in order to take principled action. The Why Mothers Die report found 'some midwives and junior obstetricians failed to pick up and act upon warning signs of common medical conditions unrelated to pregnancy'5. Associations between medical conditions and mortality are outlined in Appendix 1.1.

Ironically, a midwife is increasingly likely to encounter women with a medical disorder at a time when the pool of dual-qualified nurse-midwives is diminishing in the UK. This should place emphasis on inclusion of medical disorders within midwifery direct entry education programmes, although curriculum guidelines place emphasis on normality6. Indeed, the value of medical placements for student midwives was established7 in 1996, and individual British midwifery courses may run a module covering medical disorders sometimes addressed as 'altered health states'.

Until 2008, no textbook on pre-existing medical disorders written specifically for midwives existed. Our experience in Leicester found student midwives unenthusiastic about standard medical textbooks, due to the lack of midwifery emphasis, and they resorted to home internet use with inherent risk of simplistic understanding. Poor computer and internet access for midwives and lack of confidence with accessing the NHSnet is well identified8 as are concerns about the reliability and credibility of some medical information on the internet9.

This led to the decision to create a book specifically for mid-wives and student midwives, using local and national expertise from midwives, obstetricians and physicians. In Leicester and other parts of the UK there is a well-developed system of high-risk specialist antenatal services to provide care for women with potential medical complications in pregnancy. Care in these clinics is multi-disciplinary, and care pathways are tailored to individual maternal needs.

The multi-professional authorship suits the current ethos for 'educating for professional pluralism to minimise arrogance and dominance without diluting professional uniqueness'.10 Necessity for an inter-professional culture has already been established11 with a need to improve teamwork in the maternity services12. It is the aim of this book to contribute towards this.

Such a book may invite scrutiny, as midwives are identified as being practitioners of normality. Midwives interested in complicated pregnancy might find themselves dubbed 'med-wife' rather than midwife! However, midwifery responsibilities include 'Maximising normality for women in high dependency care' and 'Recognising deviations from normal. Making appropriate referral and working as equal partners in a multi-disciplinary team.'1

With the midwifery emphasis, there are some differences from traditional medical textbooks. In particular, differential diagnosis has not been addressed as this is very much the art of medicine. We have taken the stance that most women will already have had their medical disorder diagnosed when she meets the midwife at the booking appointment.

The book is divided into chapters, then into sections using a template for each medical condition. The first page of each is predominately non-pregnancy, giving an explanation of the condition (which might include investigations), complications and non-pregnancy treatment, and then preconception care is addressed. The second page identifies key issues pertinent to the ante-, intra- and postpartum periods in the left-hand column. Then in the right-hand column the management and care by both midwife and doctor is outlined. This allows a midwife to go quickly to the access point, for all the conditions, which often suits pressurised practice circumstances. Each chapter has its own appendix which addresses additional factors that did not fit the template concept. This text concentrates on facts and essential action, so midwives will need to consult more substantial texts for in-depth understanding.

Risk scoring is complicated13 but the terms low- and high-risk are used daily, so each section identifies risk as low, variable, high or life-threatening. This allows a midwife to recognise the potential severity of a condition immediately, which will influence decisions at the booking interview.

We could not cover all conditions, and some inclusions are not strictly speaking medical disorders, e.g. alcohol and drug abuse. However Appendix 16.1 showing associations with infant death should make the reasons behind their inclusion apparent.

The book is intended for midwives practising on British and European Union influenced models, where the midwife is part of a multi-disciplinary team referring mothers with problems to a doctor and assisting the latter where appro-priate14. Therefore, midwives in the EU, UK and British Commonwealth should find the book beneficial, with appropriate allowances for national differences.

In addition to the sterling work of the contributors we have received assistance and guidance from the practitioners below, who have been generous with their time and advice in relation to specialist subjects. We are truly indebted to:

Alison Kinder MRCP MB BS BMedSci

Consultant Rheumatologist at the University Hospitals of Leicester NHS Trust

Sue Dyson RGN RM BSc EdE MSc PhD Principal Lecturer in Nursing at De Montfort University, and Research Associate at the Unit for Social Study of Thalassaemia and Sickle Cell

Barbara Howard RGN RM BSc ENB:405,904,998 Neonatal Lecturer-Practitioner at the University Hospitals of Leicester NHS Trust

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